1- Department of Emergency Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. , dr.sfakharian@gmail.com 2- Department of Emergency Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. 3- Research Center in Emergency and Disaster Health, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

1. Introduction
he main mission of hospitals in the health system is to provide quality care for patients, and fulfill their needs and expectations. Today, patient’s satisfaction is an important principle in health care system. In 1983, the United States Department of Health and Human Services required all US health service providers to use the suggestions of those who receive the services, and consider these ideas in assessing the training programs designed for their personnel. England’s National Health Service (NHS) defines quality health care as “providing the right services to the right people at the right time in a proper and practical way affordable for the average person in the society and in a humane way” [1].
Emergency Department (ED) is the gatekeeper of health care system for patients. Therefore, the quality of services provided in this department must be improved to increase patients’ satisfaction with the services. Statistics show an increasing number of patients referring to EDs; this indicates the importance of thoughtful planning for improving the health system services according to the patients’ needs. Learning the viewpoints, needs, and demands of clients is a necessary step in the process of thoughtful planning [2].
However, a wealth of evidence shows that efficient interaction in stressful environments, like the ED, is a challenge in providing quality care [3]. On the other hand, nursing services in the ED are different from those in other departments. Different patients with varying levels of care needs, ranging from low to high, refer to the EDs. Duration of staying in the ED is usually short and decisions should be made fast, however, the patients are mostly discontent with the quality of care they receive in the ED. More attention must be paid to the special needs and expectations of non-emergency patients who are an important portion of those referring to the ED. On the other hand, what doctors and nurses perceive as high quality care is not always consistent with the patients’ perception [4].
The concept of care has been described as a complex human phenomenon that has different aspects, including thinking, action, and behavior. To better understand the patients’ needs, it is very important for the medical staff to know what behaviors are regarded by the patients as caring behaviors [5]. Many previous studies examined the quality of health care and patients’ satisfaction, understanding, and expectation regarding health care services in departments other than ED or in clinics, using questionnaires assessing the viewpoints of the medical staff and health system personnel with a limited number of items. Patient’s satisfaction and expectation is an important part of the quality of care system, but few studies have examined this issue qualitatively and from patients’ viewpoints [6].
Given that each person has a subjective and unique perception of a particular phenomenon, and because we could not find any previous study similar to the present one, we aimed to identify the perception of patients referring to the EDs of Imam Khomeini and Shariati hospitals regarding the quality of care they received.2. Materials and Methods
In the present study, a qualitative content analysis method was used. Content analysis is a method for analyzing written, verbal, and visual materials, aimed at describing and interpreting a concept. The goal of this method is to determine the main features of a concept in a clear and efficient manner in order to present a concise and general picture of the phenomena that may lead to a conceptual pattern or system. Content analysis studies can be of several kinds, including quantitative versus qualitative, deductive versus inductive, or manifest content versus latent content. Being deductive or inductive is determined by the study objective [7]. The present study is a qualitative, inductive content analysis.
The study population included all patients of the Imam Khomeini and Shariati hospitals. The study sample were selected using a purposive sampling method. This method is commonly used in qualitative studies, and involves the selection of participants based on what is needed in the study, selecting only those who have some experience with the subject matter. With the guidance of experts in the field, the researcher who is an emergency medicine physician assistant, randomly selected hospitalized patients, including those with internal conditions or trauma referred to ED for emergency issues before their hospitalization; sampling was continued until reaching data saturation. Interviews were conducted with 45 patients in different departments. The study data were collected using semi-structured interviews.
The researcher who is an emergency medicine physician assistant conducted the interviews, and the interviewees were patients who had referred from ED. The semi-structured interviews were conducted individually, formally, at the bedside of the patient, and face-to-face with them. On average, each interview lasted 30 minutes. With the guidance of experts, an interview guide was designed using the main interview themes and the interview questions were extracted based on these themes. The main questions were as follows: Tell me about your experience in the ED?, Based on your experience, how do you evaluate the quality of care provided in the ED?.
Each interview began with open-ended and general questions, then the interviewee was gradually encouraged to provide detailed information on their experience of the quality of care they had received, and their expectations about how care should be provided, how much the waiting period should be, how fast the medical staff should respond in different conditions, and how the medical staff should behave.
With the permission of interviewees, the interviews were recorded, then transcribed word-by-word, and prepared to be analyzed. At the end of each interview, the interviewee was asked to provide their opinion on the questions of interview, and suggest their own questions. The Granheim’s content analysis method was used to analyze the study data; this method provides an objective, structured, and qualitative description of the manifest content of the phenomenon in question.
It has the following steps: 1) One of the fundamental steps in content analysis is the selection of the unit of analysis. According to Granheim suggestion, each interview is regarded as a unit of analysis; 2) Each transcribed interview (as a unit of analysis) is read several times, and the recorded material is also listened to several times to get the overall sense of the content. 3) Each meaning unit includes conceptually or structurally related words and sentences that convey the same concept. Meaning units were identified in interviews. In the present study, the meaning units are referred to as codes. 4) Coded concepts from all interviews are combined to make classes. 5) Some general themes were identified through examination of different conceptual classes. Each theme described a particular aspect of the patients’ experience.
In order to increase data credibility, the following measures were taken: Prolonged engagement and persistent observation, allocation of adequate time, and good communication; Peer check, peer debriefing, and member check; and Looking for negative evidence and negative case. Constant examination, accuracy, and engagement in all stages of the study, and also clarity of the method used, gave objectivity to the data.3. Results
According to the participants’ experiences regarding the quality of health care services, some factors of patient satisfaction were found, including: (1) Factors related to hospital and ED environment: For example, the level of cleanliness or quietness of the ED according to the patients. “The ED was clean”. said patient number 2. (2) Factors related to the medical staff: Paying attention to patients’ demands and trying to fulfill them, including giving sedatives (with or without doctor’s order), blanket, sheets, and so on to the patients. “When we asked for sedatives, they gave it to us”. said patient number 19. “All my demands were fulfilled”. said patient number 27. (3) Friendliness, paying attention, and good behavior of personnel: This was mentioned repeatedly by the participants. They wanted physicians and especially nurses to be patient, pay attention to them, and be friendly. “Some staff were very nice, but others were so bad-tempered”. said patient number 6.
(4) Proper and in-time care: Going to the patient’s bedside the moment they admitted, finding their veins, and giving their medications. Patients understood that despite the low number of nurses per patients, they had received good attention and care. “They took care of the patients well, and they did everything they could, despite the fact that they were so busy”. said patient number 3. (5) Regular visiting of the patients: “When I was hospitalized, they came to my bedside in no time. They took my pulse and blood pressure…my needs were all taken care of properly and in time. When I entered the ED, they immediately changed my clothes possible”.
(6) Injecting sedatives based on patient’s demand or when necessary. Some other factors had role in patients’ dissatisfaction: (A) Medical staff’s lack of professional skills: For example, inefficiency in accessing to patient’s veins and numerous attempts to accomplish this. “Two unskilled nurses tried very hard to find my vein. They pierced my skin repeatedly. I don’t have inaccessible veins. In my previous hospitalizations, I hadn’t experience this much piercing. But this time, it was obvious they were unskilled and unable to access to my veins”. said patient number 3. (B) Medical staff’s misbehavior: Some nurses were so bad-tempered, and used a bad language when talking to the patients. “Some of them were so ill-tempered. Some nurses were so unkind. You couldn’t ask them anything at all; they answered rudely”. said patient number 6. Another form of misbehavior was shouting at the patients. “I told them ‘I am sick, I have pain, therefore I nag a lot, but this does not justify that you can shout at me”. said patient number 16. (C) Not paying enough attention to the patients’ need: For example, the patient had a problem, and asked for medication for that, but his or her demand was disregarded.
(D) Not responding to the patients’ demands for sedatives: This is the case when the patient is in pain, and asks a nurse repeatedly to give him or her sedatives, but the demand is not met. Sometime the nurse had responded that “Your physician is not available to prescribe a sedative”. (Patient number 11), making the patient very discontent. In other cases, the patient’s request had been denied with an inappropriate response: “No one has ever died of pain” or “we have to beg them to give us sedatives”, said patient number 12. So much delay in responding to the patient’s demand for sedatives: “When you ask for sedatives, there is so much delay before they provide it for you, and they don’t care you are in pain”. said patient number 22.
(E) Lack of communication between patient and physician: Physicians provided no explanation for the patients about their illness (Patient number 39). (F) Medical staff’s lack of responsiveness to the patients’ questions: The medical staff, including nurses and physicians did not give proper answers to the patients’ questions. One of the interviewees said: “The nurses and physicians didn’t provide proper answers for our questions, most of the time, they left without answering us; it seemed they didn’t want to waste their time and energy by answering us”. said patient number 36. (G) Unavailability of physicians for answering the patients’ needs.
(H) Personnel’s unresponsiveness to patients’ demands: For example, when a request is made, this is heard as the response: “I’m busy right now, wait until my free time, then I’ll listen to you”. said patient number 21. (I) Medical staff’s lack of accountability for their mistakes: One of the interviewees remarked: “My test result was lost, and they simply said it was lost, as if it wasn’t a big problem”. said patient number 37. (J) A lot of noise made by the medical staff: “Personnel themselves made a lot of noise, and talked and laughed to each other loudly, and this disturbed our rest”. said patient number 21. (K) Rejecting the patents’ demands rudely: For example, one of the participants said: “If they are unable to efficiently inject sedatives, we expect them to be at least nice to us”. said patient number 12.
(L) Limited number of personnel relative to the large number of patients in the ED. (M) Spending too much time for writing things in the medical records: Based on one of the interviewees: “The nurses and other personnel were always writing, as if they were in the classroom writing their assignments. When we asked them something, they did not listen to us as long as they were writing”. said patient number 41. (N) Transferring the patients in a careless manner: One of the patients remembered: “When I fell I didn’t had pain as much as when I was transferred for medical imaging. said patient number 42. Other factors causing patients’ discontent with the quality of care were as follows: (1) Factors related to the ED environment: Overcrowding, Too much noise, Uncleanliness, Polluted air and poor ventilation, Dirty toilets, and Inadequate light.
(2) Factors related to the management: (A) Not giving food to the patients: according to the patient number 20, despite having order for food, some patients were not given food. (B) Shortage of equipment: Patient number 43 said that “I need more accessories. There is a shortage of beds and stretchers, there is a shortage of wheelchairs”. (C) Unsuitable or broken equipment. (D) Shortage of personnel and guards with respect to the high number of patients. (E) Shortage of toilets with respect to the high number of patients. (F) Long stay in the ED (repeatedly mentioned by the participants): “We stayed too long in the ED. Three days is a long period of time to stay in the ED. The environment and equipment of the ED is not suitable for staying this long. You should only stay for several hours”. said patient number 44. (G) Difference in the quality of care in different shifts: The quality of care was lower in night shifts compared to day shifts: “Night shifts usually lack a proper management, and no one is accountable during night shifts”. said patient number 41. (H) Lack of timely cleaning: “There is blood on the ground, they clean it with a squeegee, then leave the squeegee there unclean to wash it several hours later. They at least shouldn’t leave it there in front of the patients, it must be put in the bathroom …” said patient number 29. (I) Insufficient capacity of the rooms relative to the number of patients. (J) Not paying attention to sanitation when taking care of the patients’ needs.
(3) Factors related to the role of patient’s companion: (A) The important role of patient companion in the process of providing care and treatment: “They did not create a medical file for me until my family arrived. They told me that having a companion was mandatory”. said patient number 35. (B) Giving the responsibility of the patient’s transfer to the companions. (C) Patients being bothered by the presence of patient companions, especially when there are many of them. (D) Companion’s role as the caregiver for their own patient, and sometimes for a patient on the adjoining bed who has no companion.(E) Making the patient companions involved in the care and treatment procedures.
Patients’ perception of their different experiences in the ED are: (1) Not providing treatment due to be an educational hospital. Spending too much time for writing in the medical records: “The nurses sit and write all the time, and then they hand over the shift”. said patient number 39. (B) Physicians’ and nurses’ indifference to the pain of patients: Lack of proper care for the affected limb.
(4) Factors related to the lack of notification and educational materials (proper notification and education are not provided for the patients): (1) Not giving the patients proper information about doctor’s orders, which is an inalienable right of the patients: “On a Friday night that the next day I had endoscopy, the nurses didn’t tell me that I had to refrain from eating breakfast or anything else in the morning. The next day my endoscopy was delayed, and this made me very upset. I wouldn’t eat anything, if they had told me so. It was their fault that my endoscopy was postponed... They don’t inform patients properly”. said patient number 20.
(2) Not giving the patients proper information on the treatment and care process: In other words, no explanation is provided for the patients regarding the treatment and care process. (3) Not giving the patients proper information on the triage system that is particularly important in the ED: “You should be dying so that your condition become a high priority for them”. said patient number 35. Some factors are related to psychological support for the patients. For example, a pregnant patient stated that because she was too worried, she did not pay attention to her surroundings.
(4) Lack of respect for patients’ privacy: This was particularly important for female patients, especially when nurses changed their clothes or during medical procedures like catheterization. “When they change women’s clothes, they don’t care that it can be seen through the window, and this made me very uncomfortable. They don’t even consider this during doctor visits, and on one occasion they tried to take off my clothes in the corridor; this was very hard for me as a woman, and made me very uncomfortable. During catheterization also the male doctors were in the room (outpatient operation), and it could be seen through the window”. said patient number 23.4. Discussion
In the present study, we examined the perception and experiences of the patients in the EDs of the Imam Khomeini and Shariati hospitals regarding the quality of the care provided by the medical staff. In terms of the quality of care, some factors were related to patients’ satisfaction, and some other to patients’ dissatisfaction. There were some other factors that were classified under the names patients’ perceptions, patients’ rights, and the role of patient companions.
Factors affecting patients’ satisfaction and dissatisfaction were classified in the following domains: environment, personnel, management, notification and education, psychological support, and patients’ rights. Regarding the environment, such factors as overcrowding, noisiness, cleanliness, and ventilation were mentioned by the participants. The majority of patients believed that ED is essentially a crowded and noisy place; this shows that they took this fact into consideration when evaluating the quality of ED.
Cleanliness, especially clean toilets, and such factors as proper ventilation were of high importance for the patients; this indicates that patients pay attention to details that may be too ordinary or unimportant in view of the health system. In addition, very small details that may not be very important in view of managers, create a clear image in the minds of patients. For example, timely removing the blood from the floor and cleaning the toilets was very important for the patients. The participants were concerned about sanitation. For example, they believed an unclean squeegee should not be put in a place observable by the patients, and it must be washed immediately; this indicates that despite being in pain and suffering, patients notice these issues.
In a review study on the experiences of patients in the ED conducted by Gordon et al. (2009), patients’ experiences were put into 5 categories, including ED emotions, patient-treatment staff interactions, waiting period, family, and ED environment. In this study, it was stated that a high percentage of patients admitted to the ED are afraid, anxious, helpless, and in pain, and they believe that they have a serious and life-threatening condition. In addition, patient, and treatment staff interactions in the ED typically involve medical and scientific care, but emotional, affective, and psychological care are usually neglected. Patients want to have better interactions with the treatment staff, and be informed on their illness and the treatment process in all stages.
Waiting period is an important factor in the patients’ perception about the quality of care, however, if they are informed about the reason of waiting or the exact waiting period, they can better tolerate it. The ED environment is tense and stressful for many reasons. The beds, trolleys, and stretchers are not convenient. The waiting room is also very stressful. Ed is usually crowded and noisy. In addition, patients who have used alcohol or drugs, or those who shout in pain, make other patients upset or inconvenient. Moreover, ED is usually unclean, the floor makes a lot of noise, toilets are broken and dirty, and the old patients who feel cold need blankets [8].
In a review study on the patient satisfaction with ED service by Taylor et al. (2004), the most frequently reported factors were as follows: perceived and actual waiting period, giving information to the patients about different aspects of their illnesses and treatment processes, treatment staff’s attitude, ED environment, and perceived quality of care techniques. Patient-related factors important in the satisfaction of patients included age, gender, social status, illness severity, triage level, and waiting period. Factors related to the service providers included perceived attitude of the treatment staff, interpersonal skills, notification and explanation, and aspects related to the waiting period, especially the perceived versus expected waiting period [9].
Another important factor reported by the study participants was personnel’s pleasant. This factor was very important for the patients, and a large number of the negative experiences of the patients were related to bad-tempered nurses. In a qualitative study conducted by Mahasti (2005), it was found that the following aspects in the behavior of nurses had led to a feeling of comfort in the patients: availability, humane interaction, understanding and empathy, kindness, and accountability [10].
From the patients’ viewpoints, timely care mostly refers to paying attention to them. They expected the nurses to notice them, obtain their medical history, take their vital signs, apply peripheral venous catheter and intravenous infusion, and give them sedatives, as soon as they entered the ED. Patients usually consider intravenous infusion as an integral part of treatment, but they must been informed on the fact that treatment is not necessarily started with intravenous infusion. In addition, many patients were upset about not receiving enough sedative to relieve their pain. Therefore, the importance of alleviating patients’ pain, especially in accidents or other acute conditions must be explained and clarified for the treatment staff; they must be aware that timely pain alleviation is very important in balancing the unpleasant experience of the patients and increasing their satisfaction.
In a study done by Muntlin et al. (2005), a large number of patients regarded the quality of care as poor, and it was found that there were still many issues that had to be improved. Many complaints about quality were related to the ED environment. About 20% of patients reported that they had not received enough sedatives to relieve their pain. More than 20% of patients stated that as if nurses were seemed to not interested in their work, and patients were not given accurate and useful information on their illness, how to take care of themselves, and what physicians did for them [4].
Patients expect attention, especially from nurses, so that they do not have to seek their attention for every request. In a qualitative study by Feizi et al. (2005), patients trusting their nurses was reported as an important, yet complex phenomenon, and it was shown that professionality and ethical considerations could increase patients’ trust in care providers. The professional aspects of nursing practice included knowledge, skills, experience, vigilance, passion to help others, accountability, devotion, and nurses’ relationship with their work. The ethical considerations included secrecy, honesty, and confidentiality [11].
Muntlin et al. (2006) also reported that many issues that needed to be improved were in the domain of nursing. Therefore, the importance of nursing care must be clarified for the nurses and physicians, and they have to pay more attention to the personal and unique experiences of patients [4].
In patients with organ damage and limb trauma such as fractures, complaining about lack of care and improper transportation was very common. This indicates that the staff must be trained to efficiently deal with these issues, and given that the patients stated that splinting reduced their pain, it is suggested that before a definite diagnosis and use of a plaster cast, prehospital splints be used for transferring patients from ED to radiology department. In addition, the radiology personnel and those in charge of patient transfer must be trained in efficiently transferring the patients. Moreover, the use of temporary splinting, along with training can reduce the pain in patients and prevent more damages.
Another issue is the privacy of patients as one of their inalienable rights that unfortunately is not respected according to many patients. This is especially important for female patients who reported that their privacy had been violated during changing clothes, doctor visits, and medical procedures. In a study by Feizi (2005), it was shown that respecting patient’s privacy by nurses or doctors was an ethical consideration that gained the patients’ trust. In this study, it was stated that privacy is an important issue for the majority of people, and individuals do not like other people to enter their privacy without permission. Therefore, medical staff must be reminded to consider this issue (respecting the rights and privacy of patients) seriously. Another issue is not paying attention to the patient when handing over the shift which is especially true for nurses, because they always hand over the shift at the bedside of patients. The patient should not be criticized for hearing the conversation at their bedside, and for asking about what is being said [11].
Frank et al. (2008) examined the concept of ‘cooperation in treatment’ from the patients’ perspectives; the concept was classified into three categories: 1) becoming aware, i.e., the patients wanted to receive information on their illness through direct visual and verbal communication with the medical staff, 2) the patients wanted to be involved in the treatment process, and 3) they desired transparency, that is, not being forced to do anything special, and being totally entitled to receive attention from the medical staff [12].
A study by Ebrahimi (2004) in the Iran University of Medical Sciences also showed that a common expectation by all patients was to be informed about their illnesses [13]. Feizi et al. found honesty to be the basis of building trust between patient and therapist. Many participants in this study wanted to hear the truth about their illnesses. Although they especially expected their physicians to tell them about their illnesses, regardless of their curability, treatment method, and so on. Nurses were also involved in the process of telling the truth to the patients [11].
Another important issue is that the medical staff must refrain from judging patients based on their appearances, and not to express their judgment about the patients, especially in front of them; this is particularly important in public and educational hospitals. For example, if a patient does not respond to sedatives, the medical staff should not jump into conclusion that he or she is addicted.
Another important issue is respecting the right of the patients to be admitted even if they do not have a companion. Although patients without a companion are admitted and their medical records are created, but it seems that this process is slower for these patients. Because many admitted patients to the ED do not have a companion, someone must be put in charge of admitting these patients and creating their medical record to prevent the formation of such perception in the patients that increases their dissatisfaction.
The patients also expected the timely and quick conduction of treatment procedures. Timely and quick treatment is one of the primary rights of the patients. It seems that what creates a misconception among patients about this issue is the patients’ unawareness of the correct system of triage and related ratings. Because in our culture, patients usually consider themselves more important than other patients, and feel their problem is more serious than that of others, providing information on these issues may help patients understand the definition of the really serious condition, therefore increasing the patients’ respect for the triage system in the ED, reducing their discontent with the quality of care, decreasing their improper expectations, and preventing altercations between patients and medical staff.
In a focus group study on the patients’ expectations of the quality of care in the ED by Watt et al. (2004), the expectations were divided into six categories: medical staff’s relationship with patients, a proper waiting period, triage process, giving information, quality of care, and optimization of the existing services. Many participants in this study believed that patients in Ed are usually afraid, anxious, and helpless, and expect the medical staff to pay attention to them individually, listen to them, and reassure them. They also expect to be informed on everything happens during their treatment in the ED. In this study, all patients wanted their condition to be regarded as worse than those of others. In addition, they expected a reasonable waiting period, and desired to be given an exact estimation of the waiting period in the triage system. Moreover, the medical staff believed that most patients are not aware of the triage process, but when it is explained to them, they understand and accept it [14].5. Conclusion
The study results and comparing them to those of previous studies indicate that factors underestimated by the medical system, may have a very important role in the patients’ level of satisfaction with the quality of care. Among these factors are the way medical staff deal with or behave toward patients, uncleanliness of the ED environment, psychological support, proper management and timely care, and providing information about patients’ illnesses. We can conclude that patients’ experiences were generally in five categories, including dissatisfaction, satisfaction, patient’s perception, patient’s recommendation, and role of patient companion.
Each one of the satisfaction and dissatisfaction categories also included the following subcategories: environment, personnel, management, notification and information, and patients’ rights. All factors in the subcategories were involved in satisfaction, dissatisfaction, and concepts extracted from the present research, also according to the patients, weakness or strength in each of these factors had a role in their perception of quality of medical care. In addition, due to the fact that evidence-based instruments can provide valuable information for clinical practice, the findings of the present study could be used in developing standard questionnaires.
Due to time and place limitations, the present research was only conducted in two public hospitals affiliated to Tehran University of Medical Sciences. Needless to say, conducting such a study in other public and private hospitals and in other cities, would enrich our knowledge about these issues.Acknowledgments
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Conflict of Interest
The authors declared no conflicts of interests.

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